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Agency Information Collection Activities: Proposed Collection; Comment Request

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Centers for Medicare & Medicaid Services, HHS.




The Centers for Medicare & Medicaid Services (CMS) is announcing an opportunity for the public to comment on CMS' intention to collect information from the public. Under the Paperwork Reduction Act of 1995 (the PRA), federal agencies are required to publish notice in the Federal Register concerning each proposed collection of information (including each proposed extension or reinstatement of an existing collection of information) and to allow 60 days for public comment on the proposed action. Interested persons are invited to send comments regarding our burden estimates or any other aspect of this collection of information, including the necessity and utility of the proposed information collection for the proper performance of the agency's functions, the accuracy of the estimated burden, ways to enhance the quality, utility, and clarity of the information to be collected, and the use of automated collection techniques or other forms of information technology to minimize the information collection burden.


Comments must be received by February 12, 2019.


When commenting, please reference the document identifier or OMB control number. To be assured consideration, comments and recommendations must be submitted in any one of the following ways:

1. Electronically. You may send your comments electronically to Follow the instructions for “Comment or Submission” or “More Search Options” to find the information collection document(s) that are accepting comments.

2. By regular mail. You may mail written comments to the following address: CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention: Document Identifier/OMB Control Number ____, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

To obtain copies of a supporting statement and any related forms for the proposed collection(s) summarized in this notice, you may make your request using one of following:

1. Access CMS' website address at website address at​Regulations-and-Guidance/​Legislation/​PaperworkReductionActof1995/​PRA-Listing.html.

2. Email your request, including your address, phone number, OMB number, and CMS document identifier, to

3. Call the Reports Clearance Office at (410) 786-1326.

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Reports Clearance Officer, William Parham, at (410) 786-4669.

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This notice sets out a summary of the use and burden associated with the following information collections. More detailed information can be found in each collection's supporting statement and associated materials (see ADDRESSES).

CMS-3070G-I ICF/IID Survey Report Form and Supporting Regulations

CMS-10692 Home and Community Based Services (HCBS) Incident Management Survey

Under the PRA (44 U.S.C. 3501-3520), federal agencies must obtain approval from the Office of Management and Budget (OMB) for each collection of information they conduct or sponsor. The term “collection of information” is defined in 44 U.S.C. 3502(3) and 5 CFR 1320.3(c) and includes agency requests or requirements that members of the public submit reports, keep records, or provide information to a third party. Section 3506(c)(2)(A) of the PRA requires federal agencies to publish a 60-day notice in the Federal Register concerning each proposed collection of information, including each proposed extension or reinstatement of an existing collection of information, before submitting the collection to OMB for approval. To comply with this requirement, CMS is publishing this notice.

Information Collection

1. Type of Information Collection Request: Extension of a currently approved collection; Title of Information Collection: ICF/IID Survey Report Form and Supporting Regulations; Use: The information collected with forms 3070G-I is used to determine the level of compliance with Intermediate Care Facilities for Individuals with Intellectual Disabilities Start Printed Page 64347(ICF/IID) CoPs necessary to participate in the Medicare/Medicaid program. Information needed to monitor the State's performance as well as the ICF/IID program in general, is available to CMS only through the use of information abstracted from the survey report form. The form serves as a coding worksheet designed to facilitate data entry and retrieval into the Automated Survey Processing Environment Suite (ASPEN) in the State and at the CMS regional offices. Form Number: CMS-3070G-I (OMB control number: 0938-0062); Frequency: Reporting—Yearly; Affected Public: Business or other for-profits and Not-for-profit institutions; Number of Respondents: 6,100; Total Annual Responses: 6,100; Total Annual Hours: 18,300. (For policy questions regarding this collection contact Melissa Rice at 410-786-3270.)

2. Type of Information Collection Request: New collection (Request for a new OMB control number); Title of Information Collection: Home and Community Based Services (HCBS) Incident Management Survey; Use: The Survey will be disseminated to all 51 state Medicaid agencies (including the District of Columbia) to assess incident management systems in 1915(c) waivers. States will be surveyed to identify methods and promising practices for identifying, reporting, tracking, and resolving incidents of abuse, neglect, and exploitation. The survey results will also be used to review the strengths and weaknesses of each state's incident management system and will inform guidance to help ensure compliance with sections 1902(a)(30(A) and 1915(c)(2)(A) of the Social Security Act. Form Number: CMS-10692 (OMB control number: 0938-TBD); Frequency: Once and on occasion; Affected Public: State, Local, or Tribal Governments; Number of Respondents: 51; Total Annual Responses: 102; Total Annual Hours: 153. (For policy questions regarding this collection contact Ryan Shannahan at 410-786-0295.)

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Dated: December 11, 2018.

William N. Parham, III,

Director, Paperwork Reduction Staff, Office of Strategic Operations and Regulatory Affairs.

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[FR Doc. 2018-27101 Filed 12-13-18; 8:45 am]